Viokace — Blue Cross Blue Shield of Oklahoma

off-label indications meeting compendia or peer-reviewed evidence requirements (Ohio Fully Insured or HIM Shop plans)

Initial criteria

1. Member resides in Ohio AND
2. Plan is Fully Insured or HIM Shop (SG) AND BOTH:
a. The patient does NOT have any FDA labeled contraindications to the requested agent AND
b. ONE of the following:
i. The patient has another FDA labeled indication for the requested agent and route of administration OR
ii. The patient has another indication supported in compendia for the requested agent and route of administration OR
iii. The prescriber has submitted TWO peer-reviewed medical journal articles supporting proposed use as safe and effective (randomized, double-blind, placebo-controlled trials; case studies not acceptable)

12 months